Pediatrics - Orthobullets

• PLane of motion
• Close to active physis: Prox humerus, distal radius, distal femur, prox tibia

Reserve zone: Gauchers, diastrophic dysplasia, pseudoachondroplasia

Proliferative: Achondroplasia, Gigantism, MHE

Hypertrophic: Maturation, degenerative, provisional calcification >>>>SCFE, enchondroma, mucchopolusaccahride, fracture

Primary spongiosa: Corner fractures, scurvy

Secondary spongiosa: Renal SCFE

• Hypertrophic
• Hypertrophic
• Primary spongiosa
• Proliferative
• Reserve zone

• <50% involvement
• >2 years or 2 cm or growth remaining

SMA

Progressive loss of alpha-motor neurons in anterior horn of spinal cord

Autosomal recessive

SMN gene (survival motor neuron)

• Hip dislocation
• scoliosis
• Lower extremity contractures

• Type I
• Present < 6 months
• Absent DTR
• TOngue fasciculations

Die by 2 years

• Type II
• Present at 6-12 months
• Muscle weakness worse in LE
• Can sit but cant walk
• Live up to 5th decade

• Type III
• Present at 2-15 years
• Proximal weakness
• Walk as children but wheelchair as adults

Normal life expectancy

DTR present in Duchenne

DTR absent in SMA

• Dislocation
• Leave alone

• Scoliosis
• PSF to pelvis > lso adress hip flexion contractures so kid can sit

SMA

• Duchennes
• CMT
• Spinobulbar muscular atrophy
• SMA
• Freiderich ataxia

• 4-8 years
• Lower SES
• Male: female 5:1
• Caucasian

• Family hx
• Low birth weight
• Abnormal birth presentation
• Second hand smoke
• Asian inuit and central european descent

• Protein S
• Protein C

• ADHD: 33%
• Bone age delayed: 89%

• Younger age: less than 6 at presentation
• Sphericity of femoral head and congruency at skeletal maturity
• Lateral pillar classification

50%

Perthes

• Initial stage
• Infarction produces smaller, sclerotic epiphysis with medial joint space widening
• Normal x rays

• Fragmentation stage
• Cresent sign
• Femoral head fragments due to revascularization with bone resorption and subchondral collapse

• Reossification
• Ossific nucleus reossifies

• Healing or remodelling
• Femoral head remodels until skeletal maturity

Lateral pillar: for perthes

• Group A
• Lateral pillar maintains full height: good outcone

• Group B
• Maintains >50% height: poor outcome in patients >6 years bone age with no surgery...improved outcomes with surgery if >8 years of age

• Group B/C
• Lateral pillar is narrowed (2-3mm) or poorly ossified with approximately 50% height

• Group C
• Lateral pillar less than 50% height maintained
• Poor outcomes in all patients >>no surgery

At the beginning of fragmentation stage

• Gage sing: V shaped radiolucency in lateral aspect of metaphysis
• Calcification lateral to epiphysis
• Lateral subluxation of femoral head
• Horizontal proximal femoral physis
• Meaphyseasl cyst: late addition

• Resolution of symptoms: NSAID, traction, crutches
• Restoration ROM: PT muscle lenghtening, petrie cast
• Containement: Proximal femoral osteotomy,pelvic osteotmy

Children > 8 with lateral pillar B and B/C

Hinge abduction

Goal is to reposition the hinge segment away from acetabulum during abduction

• Coxa magna
• Coxa plana
• Coxa breva
• Trochanteric overgrowth

• Gastrocs/dorsiflexors
• Plantar fascia+intrinsics/dorsiflexors
• Tib post+ tib ant/peroneous brevis
• Tib ant/peroneus longus
• Peroneus brevis/tib post
• Gastrocs+tib post+tib ant/Peroneus brevis/longus
• Gastrocs/peroneals/tib post+ tib ant
• Foot dorsiflexors/evertos/plantar flexors/inverters

Equinovarus: casued by overactive tib ant

• 18-24 months from cerebral injury (from JAAOS)
• SURGERY
• Split tib ant transfer
• FHL to dorsum of foot + release of FDL and FDS at base of each toe
• TAL or gastrocs lenghtening

• Contracted plantar fascia
• Weak tib ant overpowered by peroneus longus

• CMT
• Freidrich ataxia
• Cerebral palsy
• Polio
• Spinal cord lesions

• Plantar fascia release
• Tib post transfer to dorsum foot
• Peroneous longus to brevis
• Dorsiflexion osteotomy 1st ray
• Transfer EHL to neck of 1st MT if clawing of 1st toe
• Calcaneus valgus producing osteotomy (lateral slide or lateral closing wedge)
• TAL

Borrelia burgdorferi

• Stage 1
• 1-30 days after bite
• Rash: bullet eye rash
• Flu like symptoms

• Stage 2
• Weeks-months
• Early disseminated
• Neuro and cardiac symptoms

• Stage 3
• Arthritis
• 60% of untreated patients

Bullseye rash: Lyme disease

Doxycycline

or: amoxicillin/cefuroxime

• Tarsal coalition: sinus tarsi
• CVT: rocker bottom foot
• Accessory navicular: focal pain at navicular

• Calcaneal lenghtening or medial slide
• Plantar base closing wedge osteotomy of the first cuneiform
• Tib post shortening
• Peroneal lenghtening

Fibular hemimelia

Fibular hemimelia

• Sonic hedgehog
• Ball and ankle socket

• Anteromedial tibial bowing
• Ankle intability: bal and socket angle
• Club foot
• Tarsal coalition (50%)
• Absent lateral rays
• Femoral abnormalities ( PFFD, coxa vara)
• Cruciate ligament deficiency
• Genu valgum
• LLD

• Short limb
• Skin dimpling over midanterior tibia
• Equinovalgus foot

• Absent or shortened fibula
• Tibial spines underdeveloped
• Intercondylar notch is shallow
• Ball and socket ankle

Syme: 

Do it around age 1

• Non functional deformed unstable foot
• lld >30%
• unable to cope with multiple lengthening procedures

Cerebral palsy: mild spasticity > may delay surgery

Block presynaptic release of acetylcholine

• Diplegics with planovalgus foot
• Adductor hallucis overactivity + ER applied forces

1st MTP fusion

Equino plano valgus

Split posterior tibial tendon transfer: btw ages 4-7 with flexible equinovarus deformities

• Flat feet
• Tib post insufficiency

Tib post: innervated by tibial nerve

• Spring ligament: plantar calcaneonavicular from sustentaculum tali
• Bifurcate ligament: anterior process of calc to navicular and cuboid
• DOrsal talonavicualr ligament: neck of talus to navicular bone

• Dorsalis pedis artery
• Medial plantar artery
• Anastamosis btw 2 above mentioned

• Type 1: sesamoid on tib post
• Type 2: attached to native navicular via synchondrosis
• Type: Complete bony enlargement

• Infantile: age 0-3
• Rarely affects femur
• Bilateral

Adolescent Blount

• Age >10 years
• More likely to have femoral deformity
• More likely unilateral

• Obesity
• African american descent

Adolescent: Distal femoral+ tibia varus

Infantile: Distal femoral VALGUS and proximal tibia varus

• Narrowing tibial epiphysis
• Widening of the medial tibial growth plate
• Metaphyseal beaking
• MDA >16 degrees ( if <9 it is not blounts)

Varus deformity > 8 degrees

Proximal tibial osteotomy and placement of external fixator (gradual correction)

• Physiologic
• Renal osteodystrophy
• Morquio
• SED
• Chondroectoderma dysplasia

• Physeal injury
• Proximal metaphyseal fracture
• Fibrous dysplasia
• Osteochondromas
• Olliers disease

btw 3-4 years of age up to 20 degrees of genu valgum

Should not be worse than 12 degrees of genu valgum

> 15 degrees in a patient <10 years

Mecahnical axis falls in lateral quadrant in kid < 10 years

• Bones formed by intramembranous ossification
• Absent clavicle
• Autosomal dominant: RUNX2

• Clavicular dysmorphism
• Delayed closure of sutures
• coxa vara
• failure ossification of pubis
• Short middle phalanges

Mothers have serum antibodies that inhibit fetal acetylcholine receptors leading to a decreased number of anterior horn cells

• Upper extremity deformity
• Teratologic hip subluxation/dislocation
• Knee contractures
• CLubfoot
• CVT
• C shaped scoliosis
• Fractures

Type I: Single localized deformity (forearm pronation)

Type II: Full expression (absence of shoulder muscles, thin limbs, elbows extended, wrist flexed and ulnarly deviated, intrinsic deformity of hands, adducted thumbs, no flexion creases

Type III: type II + polydactyly + systemic manifestations

• Shoulder adducted and IR ( no muscles)
• Elbows extended (no flexion creases
• Wrist flexed and ulnarly deviated
• Intrinsic plus hand deformity
• Thumb addcuted
• Hips flexes, abducted, ER
• Knees extended
• Clubfeet

• Neurologic studies
• Enzyme studies
• Muscle biopsies

Consider after age 4 to allow independent eating

Tricep V-Y lenghtening and posterior capsulectomy at 1.5 -3 years

FCU release, lenghtening or transfer to wrist extensors, dorsal carpal closing wedge osteotomy

Z plasty syndactly

PIP arthrodesis

Medial open reduction +/- femoral shortening osteotomy

• Soft tissue releases
• Femoral angulation through guided growth
• Supracondylar femoral osteotomy

• Marked improvement within 24-48hrs
• Complete resolution of symptoms will usually occur < 1 week

Septic arthritis: painfull passive ROM

TS: painless passive ROM

• Patient able to weight bear
• CRP <20

NSAIDS

WBAT

Should resume within a week

Small undescended scapula

• Scapular winging
• Hypoplastic scapula
• Omovertebral connection between superomedial angle of scapula and cervical spine (30-50%)

Sprengel

Interruption of embryonic subclavian blood supply: at the level of subclavian, internal thoracic or subscapular

Interruption of subclavian artery proximal to internal thoracic and distal to vertebral

• Klippel-feil: 1/3 have sprengel
• scoliosis
• Upper extremity anomalies
• diastomatomyelia
• Kidney Disease

• Levator scapulae
• RHomboids
• Teres major
• Lat dorsi

SHoulder abduction: bc of loss of scapulothoracic motion

• Severe cosmetic concerns
• Abduction <120

CAN IMPROVE ROM 40-50 degrees

• Woodward
• detachment and reattachment of medial parascapular muscles at spinous process origin to allow scapula to move inferiorly and rotate into more shoulder abduction

Green procedure



extraperiosteal detachment of paraspinal muscles at the scapular insertion and reinsertion after inferior movement of scapula with traction cables

• Quad tendon contracture
• ANd subluxation of hamstring
• Absent suprapatellar pouch
• Tight Collateral ligaments

• Myelomeningocele
• Arthrogryposis
• Larsen

• DDH: 50%
• CLubfoot
• Metatarsus adductus

Reduction and casting

If hip dislocated as well treat knee first to be able to put pavlik on

• OPERATIVE
• If unable to do 30 degrees flexion after 3 months

Quad lenghtening: v-y quadriceplasty or z lenghtening

Anterior joint capsule release

Hamstring tendon posterior transposition

Collateral ligament mobilization

• Maternal duplication chromosome 21
• Col6a1: Type VI collagen >>ligamentous laxity

• Generalized ligamentous laxity
• SHort stature
• C1-2 instability
• Occipitocervical instability
• Hip subluxation and dislocation
• patellofemoral instability
• scoliosis/spondy
• pes planus
• metatarsus primus varus
• SCFE

• Mental retardation
• Cardiac disease
• Endocrine disorders: hypohyroid
• premature aging
• duodenal atresia
• alzheimers disease

• Flattened facies
• upward slanting eyes
• Epicanthal folds
• SIngle palmar crease
• ligamentous laxity
• Scoliosis

• ADI > 5mm and symptomatic/myelopathic
• ADI> 10 mm
• < 14 mm space available for cord

Powers ratio

Basion to posterior arch c1 / Opisthion to anterior arch c1

ratio > 1 suggests instability

• SOft tissue and bone fragility
• Soft tissue calcification
• Mitral valve prolapse
• aortic root dilatation
• DDH
• clubfoot
• pes planus
• scoliosis
• High palate
• Gastroparesis

COl5a1 or col5a2

Affects type V collagen: important for skin matrix and collagen on the basement membrane

5 or more: joint hypermobility

• Passive hyperextension of each small finger >90 degrees
• passive abduction of each thumb to surface of forearm
• Hyperextension knee >10
• Hyperextesion elbow > 10
• Forward flexion trunk with palms on floor and knees fully extended

Skin biopsy collagen typing

Deficiency factor VIII

Deficiency factor IX

X linked recessive: affects only males

• Hemophilic arthropathy
• Intramuscular hematoma: commonly iliacus > femoral nerve compression
• LLD: epiphyseal overgrowth
• Fractures: generalized osteopenia...heal normal time
• compartment syndrome

Treatment related inhibitors: make treatment not work....presence is a relative contraindication to surgery

Blood born infections: HIV prevalence 10-15%

Allergic reaction to infused products

Squaring of the patellaand femoral condyles

Dx: hemophilia

Jordan's sign: squaring patella and femoral condyles

• Ballooning distal femur
• Widening intercondylar notch
• long thin patella on lateral

• Normal PT
• Prolonged ott

30%

40-505

100% first week then maintain > 50% for second week

Flexion and varus deformity of IP joints

Contracture of FDL or FDB

Severe toe deformity or nail bed deformity in children >3 years

• FDL/FDB release
• or transfer FDL to extensor surface

• Irregular, delayed ossification at multiple epiphysis
• Autosomal dominant
• COMP
• Dysproportionate

MED

MED

Overuse injury of calcaneal apophysis

Sever's disease

COnservative only...no surgery

• Post axial: lateral aspect of foot
• Autosomal dominant: positive fam hx

• Post axial
• Y-metatarsal
• T metatarsal
• wide metatarsal head
• complete duplicatio
• Central: Duplication of 2-4 toe

Pre axial

Freidrich ataxia

• Dorsal root gangia
• Corticospinal tracts
• Dentate nuclei
• Senory peripheral nerves

• Autosomal recessive
• Frataxin

• Cavus foot
• Scoliosis
• Cardiomyopathy

• Ataxia
• Areflexia
• Positive plantar response

• Absent hip
• Femoral neck pseudoarthrosis
• absent femur
• Shortened femur

• Sonic hedgehog
• Primary ossification center

• Fibular hemimelia: 50%
• ACL deficiency
• COxa vara
• knee contractures

PFFD

Limb lenghtening: 20% per lenghtening...if LLD < 20cm

Knee arthrodesis with foot ablation: Foot is proximal to contralateral knee

Femoral pelvic fusion: absent femoral head

• Van ness: ipsilateral foot at level of contra knee
• ANkle >60 % motion

Amputation: femur lenght < 50% contralateral

• Femoral anteversion
• Metatarsus adductus
• Internal tibial torsion

• 3-6 years
• resolves by age 10

• DDH
• Metatarsus adductus
• COngenital torticollis

• ER> 70
• < 20

• Late pregnancy
• First preganncy
• Twins
• Oligohydramnios

Serpentine foot

• Residual met adductus
• TN lateral subluxation
• Hindfoot valgus

Hindfoot valgus: skew foot

Medial crease

Rigid or flexible

Autosomal dominant

Anterolateral 

• Ectrodactyly
• Preaxial polydactyly
• Ulnar aplaisia

Stability of knee joint

Knee disarticulation: absent tibia, no active extension

Syme with tib fib synostosis

Brown procedure: centralize fibula under femur: high failure rates

• btw 2nd 3rd
• Autosomal dominant
• Simple or complex: if bony fusion present or not

• Familial syndactyly
• DOwns
• Klippel feil syndrome

• AD: Filamnin B
• AR: carbohydrate sulfotransferse 3

• Hand deformities
• Scoliosis
• CLubfeet
• Cervical kyphosis

• Flattened nasal bridge
• Hypertelorism
• Prominent forehead

• Cervical kyphosis
• In first 18 months

Larsen

• Btw semimembranosus and medial head of gastrocs
• Observatin: most resolve spontaneously

inferior femoral neck

• Devlopmental
• COngenital: PFFD, short femur
• Acquired: SCFE, infection, perthes
• Dysplasia: SED, OI
• Cretinism: congenital hypothyroidism

• Neck shaft angle < 120
• Short femoral neck, vertical physis
• Increased HE angle: normal <25 degrees
• inverted y radiolucency

• HE angle > 60
• HE angle 45-60 and symptomatic
• Neck shaft angle <110

HE angle < 38

• Maternal diabetes
• Preserved protective sensation in sacral agenesis

Prominence of last vertebrae: sacral agenesis

• Right side
• Extrinsic compression by subclavian artery
• None

Only if symptomatic: orif with iliac crest bone graft

• Pancreatic islet cell hypertrophy > repeated hypoglycemia
• Wilms

• Overgrowth
• Abdominal wall defect
• Macroglossia

Staph aureus

• Hip rests in position of flexion
• Psoas sign: pain with flexion and IR

Perc drainage

• B-glococerebrosidase
• AR
• Ashkenazi jews

• Bone pain
• AVN
• Elevated levels of glucocerebrosides in blood

Failure of formation of epiphysis

Diastrophic dysplasia

Persistent autoimmune inflammatory arthritis lasting > 6 weeks in patient <16years

Knee > hand/wrist > ankle > hip > c spine

must be present

• rash
• presence of RF
• iridocyclitis
• c-spine involvement
• pericarditis
• tenosynovitis
• intermittent fever
• morning stiffness

Acute jra with rash, splenomegaly, rash, multiple joint involvement

• Polyarticular: >5 joints involved
• Pauciarticular: <5 joints involved
• Systemic: stills disease

only positive in <15%

• Etanercept: TNF inhibitor
• Rituximab: Chimeric monoclonal antibody to cd20
• Azathioprine: purine synthesis inhibitor

Iridocyclitis

Radial head dislocation + proximal ulna #

• Type I: apex anterior prox ulna + ant radial head dislocation
• Type II: Apex posterior angulation + posterior radial head dislocation
• Type III: Apex lateral ulna + lateral radial head dislocation
• Type IV: Radius + ulna # at the same level + anterior dislocation radial head

• Type I: Elbow flexion
• Type II: Full extension
• Type III: Full extension + valgus mold

Immobilize in supination

Black increased risk

Under low oxygen conditions the affected blood cells become sickle shaped and are unable to pass through vessels efficiently

• Sickle cell crisis
• Osteomyelitis
• Septhic arthritis
• AVN
• Bone infarcts
• Growth retardation
• Dactylitis: acute hand or foot swelling

Sickle cell: bone infarct

Hydroxyurea

Salmonella but staph aureus still more commonQ

Oxygen supplementation and IV hydration sidelines

Sickle cell

• FOlate deficiency
• Maternal hyperthermia
• Maternal diabetes
• Valproic acid

• Pathologic #
• spine deformity
• hip dysplasia: dislocation + contractures
• Knee deformities: tibial torsion + contractures
• Foot deformities

• Mostly wheelchair bound
• Good prognosis for independent walking

Myelodysplasia: leads to anaphylaxis

Spina bifida oculta: defect in vertebral arch with confined cord and meninges

meningocele: protruding sac without neural elements

Myelomeningocele:protruding sac WITH neural elements

Rachischisis: neural elements exposed with no covering

Myelodysplasia: obtain in second trimester

Thoracic level

Consider tethered cord in rapidly progressing deformities

L3: unopposed hip flexion and adduction

Marfan syndrome

• Arachnodactyly
• Scoliosis
• Acetabular protrusio
• Ligamentous laxity
• Recurrent dislocations
• flat foot
• Dural ectasia
• MEningocele
• Pectus excavatum/carinatum

marfans

• aortic root dilatation
• aortic dissection
• mitral valve prolapse

marfans

• Scoliosis
• Dural ectasia

Defective osteoclast resorption:Dense bone and obliterated medullary canals

Osteoclast unable to acidify Howship lacuna

• Malignant autosomal recessive
• Intermediate autosomal recessive
• Benign autosomal dominant: most common

• Cranial nerve palsy
• Spondylolysis
• Coxa vara
• Long bone fracture

Osteopetrosis

• Bone marrow transplant
• High dose vit d
• interferon gamma 1beta

• Avascular necrosis of navicular
• Short leg walking cast reduces duration of symptoms
• Not indicated

• Calcaneovalgus foot
• LLD 3-4 cm
• Only for LLD: epiphysiodesis planned
• Intrauterine positioning

External tibial torsion + femoral anteversion

• > 8 years + >40 degrees ER
• Supramalleolar rotational osteotomy

Superolateral

• Internal tibial torsion: thigh foot angle > 10 degrees
• Metatarsus adductus: medial deviation of forefoot
• femoral anteversion:  >70 IR + <20 ER

• pain
• Family hx dysplasia
• LLD
• >2SD from normal

• Tib post
• Failed non op

Rapid deceleration or hyperextension of the knee

• I: non displaced (<3mm)
• II: minimally displaced with intact posterior hinge
• III: Completely displaced
• IV: Completely displaced + comminuted

Aspirarion knee > closed reduction (bring to full extension > immobilize in full extension

• 12-16
• Eccentric quad contraction

• Primary: proximal tibia physis
• Secondary: tibial tubercle

Primary: from posterior to anterior

Ogden

• I: through Secondary ossification centre near patellar tendon insertion.
• II: # btw ossification centers
• III: coronal extending posteriorly across primary ossification center
• IV: ACross entire proximal tibia physis
• V:Periosteal sleeve avulsion from tibial tubercle

Type I/II ogden displaced<2mm

Valgus deformity: cozen phenomena > expect to resolve spontaneously within 24 months

Long leg cast in extension with varus: aim for overcorrection

• Fibular #
• Fibular #
• Tillaux
• Triplane

• Center
• Medial
• Anterolateral last

Delbet

• I: Transphyseal with or w/o dislocation
• II: Transcervical
• III: Basicervical
• IV: Intertrochanteric

Coxa valga

Coxa vara

Lateral ascending epiphyseal branches of medial femoral circumflex

Less than 4 yrs: except delbet IB + UNDISPLACED

Delbet I + II: 2mm translation, <5 degrees angulation + no malrotation

Delbet III + IV: <10 degrees angulation

Posteromedial displacement of radial and ulnar shafts

• If undisplaced > long arm cast
• If displaced: CRPP

Child abuse

Tardy ulnar nerve: from cubitus varus

SH 2

• SH 1
• SH 2

Epiphysis > GT > LT

80%

• I: minimally displaced (<5mm)
• II: Displaced <1/3 shaft
• III: Displaced 1/3 t0 2/3 of shaft
• IV: displaced >2/3 of shaft

• Any angulation
• Up to 60 degrees
• Up to 45 degrees

> 45 degrees angulation or > 2/3 displacement and less than 2 years of growth remaining

Technique: traction + abduction 90 degrees + ER >>>>> 2-3 lateral pins

• long head biceps
• joit capsule
• infolded peiosteum
• deltoid muscle

Bicipital tuberosity and radial styloid 180 degrees from each other on AP

Coronoid process and ulnar styloid 180 degress on lateral

• < 15 angulation + 45 malrotation + 1 cm bayonet
• <15 angulation + 30 malrotation + no shortening
• <10 angulation + no malrotation or shortening

• Supination injury:Pronation
• Pronation injury: Supination

• Radial head subluxation
• Traction with arm extended
• Subluxation radial head + annular ligament interposition
• Supination and flexion past 90

• Avulsion AITFL
• ER
• SH 3

Central > posterior > medial  > anterolateral

IR

Displacement > 2mm after attemped closed reduction

Percuatenous if closed reduction accepatable or open

• 3-4 weeks
• 6-8 weeks

• Angulation >10 degrees
• <50% apposition
• > 1 cm shortening

• 1-3
• Rotational
• Spiral
• Long leg cast

• SH 2: coronal on lateral
• SH 3: sagital on AP

Medial epicondyle avulsion #

• Hasmtrings and adductors
• Rectus femoris
• Sartorius
• Abdominal muscles
• Iliopsoas

2-3 cm displacement

• pathologic #
• 30 degrees

OI

medial: 80%

ORIF if extensor mechanism not intact

Trauma

If < 6y.o. need cut out in spine board: larger head can flex unstable spine c spine injury

80 + agex2

75-80 cc/kg

• Prematurity
• Anoxic injuries
• Perinatal infections: toxoplasmosis, rubella, CMV, herpes simplex, ToRCH

Independent sitting by age 2

• Spastic: velocity-dependent increased muscle tone and hyperreflexia...simultaneous contraction of agonist and antagonist muscles
• Athetoid: Constant succession of slow writhing involuntary movements.
• Ataxic: Characterized by inability to coordinate muscle movements
• Mixed
• Hypotonic

• Quadriplegic: non ambulatory
• Diaplegic: Legs>arms
• Hemiplegic: arms and legs on one side of the body

• I: near normal gross motor, independent ambulator
• II: Walks independently, difficult uneven surfaces, minimal ability to walk
• III: Walks with assistive devices
• IV: Severely limited walking ability. Wheelchair
• V: Non ambulator with global involvement. dependent in all aspects of care

Cerebral palsy

• COmpetitive inhibitor of presynaptic cholinergic receptors 
• 2-3 months

• age 4-8
• Ambulatory spastic diplegia
• Stable gait pattern limited by spasticity

Spastic adductors and hip flexors lead to scissoring

• Reimer index <33%: hip abduction <45 degrees
• Boto +/- adductor/psoas/hamstring

Hip subluxation: broken shentons line..Soft tissue release + VDRO +/- acetabular procedure

• >100%
• Open reduction + VDRO + shortening + pelvic osteotomy

• Children >4 years 
• Reimers migration index >60%

Femoral head resection and valgus support osteotomy

Crouch gate

• Hip flexion
• knee felxion
• Ankle dorsiflexion

Rectus femoris firing out of phase

• Medial lengthening
• Lateral may result in exessive weakness

• Medial hamstring lengthening
• Guided growth
• Distal femur extension osteotomy
• Rectus transfer

Stiff knee gait: transfer it posterior to center of rotation of the knee

• Incision level of the myotendinous junction
• Identofy and protect sural nerve
• Sharply divide tendon only

Goal of treatment is dorsiflexion >10 degrees

Absent heel strike + excessive plantar flexion in the swing phase

• Equinus
• Hallux valgus
• Equinoplanovalgus
• Equinocavovarus

Equinus

Inbalance of ankle dorsiflexors and plantar flexors > plantar flexion

• Shoulder IR contracture
• Forearm pronation elbow flexion 
• Wrist flexion
• Thumb in palm
• Finger flexion

Severe contracture >30 degrees interfering with hand function

Shoulder derotational ostetomy and subscapularis and pectoralis lenghtening

• LAcertus fibrosus release + biceps/brachialis lenghtening,
• brachioradialis origin release

Pronator teres transfer to anterolateral position

• Morquio
• Hurler
• Hunter

Lysosomal storage disorders due to abnormal breakdown products(mucopolysaccharides) accumulation

• Proportinal dwarfism
• Carpal tunnel
• C1-2 instability
• Hip dysplasia
• Abnormal epiphyses
• Bullet shaped phalanges
• Genu valgum

mucopolysaccharidoses

Morquio syndrome

• Galactosamine
• Cartilage at growth plate
• Autosomal recessive

Morquio

• Odontoid hypoplasia: instability
• Thoracic kyphosis
• Vertebral beaking

Hurler syndrome

Hurler syndrome

Autosomal recessive

San filippo syndrome: autosomal recessive

X linked recessive

Morquio

Duchenne muscular dystrophy

X linked recessive: only affects men

• Calf pseudohypertrophy
• Scoliosis
• Equinovarus foot deformity
• Joint contractures

• Cardiomyopathy 
• Static encephalopathy

• Unable to ambulate independently by 10
• Wheelchair dependent by 15
• Die by age 20: cardio resp

Duchenne

Rises by walking hands up legs to compensate for weak glut max and quad

Duchenne

corticosteroids

Curve >30 degrees

• SH 2
• Valgus loading

CRITOE

• O brien
• I:<30 degrees
• II: 30-60 degrees
• III: >60 degrees

• Visualization of radial head
• Elbow flexed at 90 thumb pointing up beam at 45 degrees

• <30 degrees: immobilization
• 30-60 degrees: closed reduction> bring to <30 degrees

• residual angulation >30 degrees
• 3-4 mm translation
• <45 degrees pro/supination

• patterson: extsnion varus and push radial head
• Israeli: pronate foreram flex to 90 and direct pressure

• k wire joystick
• Retrograde insertion pin across fracture sit + rotate pin

Irreducible dorsal dislocation of navicular on talus causing rigid flatfoot

• Myelomeningocele
• Arthrogryposis
• Diastematomyelia

• Bony: irreducible dorsolateral navicular dislocation + vertical talus + calcaneus eversion
• SOft tissue: Peroneus longus + tib post act as dorsi flexors + achilles contracture

TN subluxation that reduces with forced plantarflexion

CVT

Forced plantar flexion lateral x ray: Line drawn across talus passes below first metatarsal cuneiform axis

Casting followed by soft tissue release/lengthening + open reduction and pinning of TN joint

• Infantile: 2-5...bilateral
• Adolescent:>10...unilateral

Mechanical overload in genetically susceptible individuals: leads to osteochondrosis medial plateau > physeal bar

• Overweight
• Early walker
• Hispanic and black

• Persistent physiologic varus
• Rickets
• OI
• MED, SED
• Metaphyseal dysostosis
• Focal fibrocartilage defect
• TAR 
• Proximal tibia physeal lesions

• NOrmal if <2 years
• neutral around 14 months
• Genu valgum 3 years

For blounts

• Blounts
• Line connecting metaphyseal beaks and lin" 95% down the shaft
• >16 abnormal
• <10: 95% chance resolution

• KAFO
• Stage I-III in children <3 years
• Bracing for 2 years: improvement
• Improvements should occur after one year

• Stage I-II: children >3
• Stage III-VI
• Age >4
• Failure brace
• Metaphyseal diaphyseal angle >20

• Tib/fib valgus osteotomy: overcorrect by 15 degrees
• Growth modulation: more for adolescent
• Physeal bar resection
• Hemiplateau elevation

• Langenskiold
• I-IV: increasing meta diaphyseal beaking and sloping
• V-VI: Physeal bar

5.25/year

• <9: 30 degrees
• >9: 20 degrees

0.8: more than that leads to increase in failure

Pronation

Supination

4

Lateral condyle #

I: fracture lateral to trochlear groove > more stable

II: fracture through the trochlear groove

• Lateral condyle
• Based on displacement
• <2mm: intact hinge > casting
• 2-4mm: intact articular cartilage on arthrogram > CRPP
• >4mm: or compromised articular surface on arthrogram ORIF

Internal oblique: best shows mont of displacement

Stiffness

Posterior dissection

Tardy : from malunion > overgrowth tethers nerve..cubitus valgus!!

FLexor/pronator mass/MCL

• Pronator teres
• FCR
• PL
• FDS
• FCU

Excess valgus stress: FOOSH +/- elbow dislocation

• <5mm 
• 5-15mm: controversial
• Fibrous union

• Entrapment in joint
• Extends into medial condyle

• Ulnar nerve dysfunction
• >5-15mm displacement
• Displacement in valgus stress athletes

• Congenital
• Paralytic
• Physis disruption

• Hemihypertrophy
• Dysplasia
• PFFD
• DDH
• Unilateral clubfoot

SHoe lift/observation

COntralateral epiphysiodesis

• Bony bridge <50% physis
• >2 years growth remaining

• 5-7 days post op
• 1mm/day
• Keep distraction as many days as lengthened

• Autosomal dominant
• NF1 gene on chromosome 17q21

• Scoliosis
• Anterolateral bowing tibia
• Bowing of forearm bones with obliteration of medullary canal: radial/ulnar pseudoarthrosis
• Neoplasias

• NEED >2
• >6 cafe au lait spots >5mm diameter(prepubertal), >15mm diameter (postpubertal)
• >2 neurofibromas or 1 plexiform neurofibroma
• Freckling in axillary or inguinal region
• Optic glioma
• >2 lisch nodules (iris hamartomas)
• Distictive osseous lesion: sphenoid dysplasia or CPT
• 1st degree relative with NF

NF1

• NF 1: von recklinghaussen disease
• NF2: Bilateral vestiblular schwannomas
• Segmental NF: NF1 but single body segment

• Plexiform neurofibroma
• Wilms tumor

• Vertebral scalloping
• Pencilling ribs
• ENlarged foramina

Neurofibromatosis: neurofibroma on nerve roots

• PSF: high failure rate 40% pseudo
• ASF+ PSF: 10% pseudo

NF 1

• Anterolateral: CPT
• Posteromedial: Physiologic
• Anteromedial: Fibular hemimelia

• NF1: found in 50-55% patients with anterolateral bowing.
• 6% of pt with NF will have anterolateral bowing

• NF 1
• Fibrous dysplasia: 15%

• 1: Presence or absence of #
• 2: Age of presentation
• -early onset: <4 years
• -late onset: >4 years

• Look for apex anterolateral bowing
• Look for cafe au lait spots

Children ambulatory without pseudoarthrosis or fracture: goal is to prevent further bowing and fractures

Bracing in clamshell orthosis or PTB orthosis: keep until skeletal maturity

ORIF

• Resection of pseudoarthrosis to normal bone
• Correct alignment
• Bone graft and internal fixation
• Im fixation preferable

Free vascularized fibula graft from contralateral side (ipsilateral is part of pseudoarthrosis)

CPT

• I:Benign > bowing with medullary sclerosis
• II: Failure tubulation with constriction of cortical diameter
• III: Cystic
• IV: Pseudoarthrosis > narrowed tapered ends

Tibia allograft/autograft as strut placed posteriorly bridging pseudoarthrosis site

• No need to wait until >4yrs
• Earlier intervention correlates with higher risk amputation

Valgus

Benign anterolateral bowing

• SH 2
• Thurston hollland: Tension side

• 3
• 9
• 6
• 5

• Non displaced
• 6-8 weeks Above knee

• SH grade
• Displacement
• Open fracture
• Violation of hardware

• Predicted LLD > 2-6cm
• Physeal bar <50%
• > 2 year or 2.5 cm of growth left

Achondroplasia

• Autosomal dominant: sporadic in 80%
• FGFR3: inhibits chondrocyte proliferation in proliferative zone

• Obesity
• Hearing loss
• Tonsillar hypertrophy
• Frequent otitis media

• Lumbar stenosis: short pedicles + thick facet/ligamentum
• Thoracolumbar kyphosis
• Foramen magnum stenosis

• Humerus shorter than forearm + femur shorter than tibia + normal trunk
• Achondroplasia

Achondroplasia

• Trident hands
• Genu varum
• Radial head subluxation
• Muscular hypotonia

Achondroplasia

• Short pedicles
• Decreased interpedicular distance L1-S1
• Vertebral wedging > thoracolumbar kyphosis
• Posterior vertebral scalloping

• Champagne glass pelvis
• Squared iliac wings
• Inverted V in distal femoral physis

• -Obserbation: if persistant wedging >3 yrs bracing
• -Failed conservative + kyphosis >45-60 degrees

• Achondroplasia
• Sleep apnea or cord compression

• Type I collagen formation: 
• -Abnormal production
• -Decreased production

Effect: Physeal osteoblast cannot form sufficient osteoid. Periosteal osteoblasts cannot form osteoid > cannot remodel

-Col 1A1 + COL 1A2: abnorml collagen crosslinking secondary to glycine substitution in procollagen molecule

• Autosomal dominant: Mild..type I and IV
• Autosomal recessive: Severe II and III

Fractures heal in normal fashion but bones dont remodel>>>>> leads to bowing

• -Bone fragility/fractures
• Ligamentous laxity
• Short stature
• Scoliosis
• COdfish vertebrae (compression #)
• BAsilar invagination
• Olecranoon apophyseal avulsion #
• Coxa vara

OI compression #

• -Blue sclera
• -Dysmorphuc triangle shaped face
• -Hearing loss
• -Brownish teeth
• -Wormian skull bones
• -Hypermetabolism: risk of malignant hyperthermia
• -Cardio: mitral valve prolapse, aortic regurgitation

• Mitral valve prolapse
• Aortic regurgitaion

OI

OI

• Sillence
• I-II
• III-IV

• -Autosomal dominant: Quantitative disorder
• -Blue
• -Mildest: Presents late. Type A/A depending on tooth involvement. Hearing deficit 50%

OI type I

Type II: Autosomal recessive quantitative disorder

• -Normal
• -Autosomal recessive: Qualitative disorder
• -# at birth: most severe survivable type

• Normal
• Autosomal dominant: qualitative disorder
• Bowing + Vertebral fractures

• Autosomal dominant
• Hypertrophic callus after fracture

Think OI

ALP

OI with Bisphosphonates

• Curve < 45 degrees: no bracing > fragile ribs
• Curves > 45 if mmild...curve >35 if severe

Glycine

Basilar invagination

Think abuse

Transverse or short oblique

-Pavlik

-6m to 5 year: if <2-3 cm shortening early spica. If >2-3 cm traction with delayed spica/Flexible nails/ex fix/submuscular plating

5-11 years: Length stable flexible nail...Length unstable submuscular plating

11 years or more: <100 lb flexible nail...>100lb IM nail

• <10 coronal
• <20 sagital
• <10 rotation
• < 2cm short

• 2-2.5 cm above physis
• 0.4 diameter x 2 nails

Medial circumflex: deep branch

Loss of reduction

• COngenital: most common
• Acquired: trauma, degenerative, infections

• 8-12
• 12-15

Rigid flatfoot:

• Flattening arch
• Forefoot abduction
• valgus hindfoot
• peroneal spasticity

CN

CN coalition

• TC coalition
• along with talar beaking

COnservative: Below knee weight bearing cast x 6 weeks: 30% improve

% posterior facet involvement: if <50% can do resection + interpostion

If less than 20 degrees hindfoot valgus no need for valgus heel osteotomy

• Bone wax
• Fat
• EDB: in CN
• Split FHL: TC

Lateral approach: Between extensor tendons and peroneal

Protect superficail peroneal/sural nerve

Retract EDB distally

Leave 1 cm after excicing bar

Interpose tissue

• Medial approach
• between fdl and NV bundle

Upper trunk: c5-6

Lower trunk C8-T1

• Large baby
• multiparous
• difficult presentation
• Shoulder dystocia
• forceps
• breech
• prolonged labor

Internal rotation contracture: caused by brachial plexopahty> glenoid retroversion+humeal head flattening + post humeral head subluxation

90% recover without intervenetion

• Lack bicep at 3 months
• Preganglionic injuries: avulsion from cord
• Horner syndrome
• C5-7 involvement
• Klumpke's palsy

• C5-6
• Paralysis deltoid + biceps: intact wrist/fingers
• Waiter's tip: arm adducted + IR, Forearm pronated + extended elbow

Brachial plexus injuries

• 0: no motion
• 1: motion present but limited
• 3: normal motion

• C8-T1
• Claw hand: wrist in extension + hyperextension MCP + flexion IP

• < 40 degrees: serial night extension splint
• >40 degrees: extension casting

• Flail arm at 1 month
• Horner s at 1 month: preganglionic injury
• Lack of antigravity bicep 3-6 months

18 months

• Peroneus brevis
• Tib ant
• Intrinsics hand and foot

• Autosomal dominant most common
• Duplication on chromosome 17: PMP 22

• Pes cavus
• Hammer toes
• hip dysplasia
• scoliosis

Type I: Demyelinating

• Autosomal dominant
• onset 1-2 decade 
• leads to cavus foot

Type 2: Wallerian degeneration

• Less disabled
• Onset 2nd or later
• Leads to flaccid foot

• Plantarflexed first ray: initial deformity
• Cavus: peroneus longus >> weak tib ant
• Varus: Tib post >> weak peroneus brevis

Lateral heel and lateral forefoot post

• Tib post to dorsum: improve dorsiflexion
• Peroneus longus to brevis
• TAL
• 1st metatarsal osteotomy
• Plantar fascia release

• TAL
• Dorsal closing wedge 1st meta osteotomy
• peroneur longus to brevis
• tib post to dorsum
• Calcaneal osteotomy

Left thoracic and kyphotic curve

CMT

Rigid cavus + arthritic changes

• Hawaians
• Males

• CAVE
• Midfoot cavus: tight intrinsics, FHL, FDL
• Forefoot adductis: tight tib post
• Hindfoot varus: Tight achilles
• Hindfoot Equinus: tight achilles

As early as 12 weeks

90%

9-10 months so kid can walk at age 1

1: correct cavus with forefoot supinated + correct heel varus /forefoot adduction by rotating around head of talus + correct equinus +/- TAL

Abduction goal is 70 degrees

dennis brown bar shoes x 3 months 23 hrs then until age 4

tib ant transfer if dynamic supination

Lateral cuneiform

Non compliance

Clubfoot: dorsiflexed first metatarsal

• Prematurity
• C section
• Treated in NICU
• Invasive procedure

• Hip
• Shoulder
• Elbow
• Ankle

Proteolytic enzymes > articular damage within 8 hours

• Gonorrhea
• Group A strep
• Group B strep
• Staph

• Age < 6 months
• Associated osteo
• Delay > 4days presentation
• Hip >>>knee

• Flexion
• Abduction
• External rotation

• WBC > 12 000
• Inability to WB
• Fever > 38.5
• ESR >40

• > 50 000
• >50 less than serum levels
• High due to gram =ve cocci or gram -ve rods

Gonorreah

• 1st gen cephalosporin
• 2-3 gen cephalosporin
• 1st gen cephalosporin
• Oxacillin

• 6 years
• male 2.5x
• Metaphyseal: hematogenous seeding

• DM
• Hemoglobiopathy
• RA
• Renal disease
• Immune compromise
• Varicella

Staph

• GBS
• Pseudomonas
• Salmonella

Outer layer of new bone formed around abe]cess

chronic abcess surrounded by sclerotic bone + fibrous tissue

• Periosteal bone formation
• osteolysis
• mataphyseal rarefaction +/- abcess

4-6 weeks

less than 5 years

• first born
• unplanned pregnancy
• premature
• disabilities
• Step children

• Single parent
• recent social stressor
• unemployment
• Drug-use
• Personal hx of abuse
• lower SES
• lack support system

• Metaphyseal corner #: primary spongiosa
• rib fractures
• Spinous process
• Sternal
• # at different stages of healing

Skin cuts or bruises

Metaphysis displaces anteriorly and superior

• Obese
• Males
• Black, pacific islanders

• boys 13
• Girls 12

• Obese
• Radiation
• Acetabular retroversion

Hypertrophic zone: weakened perichondrial ring + vertical physis

• Hypothyroid
• Renal osteodystrophy
• Growth hormone deficiency
• Panhypopit

• <10 years
• <50th percentile weight

• Stable: able to weight bear with or without crutches >0-10%
• Unstable: Unable to ambulate 20-40%

Based on angle difference!

• mild: <30
• Mod: 30-50
• severe: >50

Irritation of obturator nerve

Obligtory external rotation with hip flexion

On AP: overlapping metaphysis and posteriorly displaced physis

• Age < 10
• Open tri radaite
• Obese
• Endocrine
• Stage 0-3 calc apophysis

• SCFE
• Flexion + IR + valgus

Renal osteodystrophy

• -Dislocated in utero and irreducible on neonatal exam
• -Has pseudoacetabulum
• -Neuromuscular: Arthrogryposis, myelomeningocele, larsen

• Female
• Left hip

• Native americans
• Rarely in African Americans

• Female
• First born
• family Hx
• Frank breach 
• Olygohydramnios

Anterior / anterolateral

• CONGENITAL MUSCULAR TORTICOLLIS
• Metatarsus adductus
• Congenital knee dislocation

Reducible hip

Dislocateable hip

• Barlow ortolani if <3 months
• >3 months galeazzi/ROM

Less than 25 after 6 months

• < 20 abnormal
• reliable if >5 years

• Alpha angle: Line down ilieum then bony acetabulum.. N more than 60
• beta angle: line down ileum then across labrum normal less than 55

• Inverted labrum
• Inverted limbus
• Transverse acetabular ligament
• Hip capsule: hour glass
• Pulvinar
• Ligamentus teres

DDH < 6 months

• Teratologic hip dislocation
• Spina bifida
• Spasticity

need normal muscle function

90%

• unsuccesful reduction after 3-4 weeks
• Semi rigid abduction brace x 3-4 weeks

• DDH 6-18 months
• Failure pavlik

• -Medial pool dye >7mm
• -Wide abduction: >55

• >2years + dysplasia
• Anatomic changes femoral side: anteversio/coxa valga)

<4 years old

• DDH > 2 years + dysplasia
• Increased AI

COmmonly if > 4years old

• Flexion 90-100
• Abduction 50

• AVN: impingement of the posterosuperior retinacular branch of MCFA
• Transcient femoral nerve palsy: with hyperflexion
• Pavlik disease: erosion of pelvis superior to acetabulum

Subadductor: aim for ipsilateral shoulder

• Can do capsulorraphy
• If pt >12 months

• Address blocks to reduction + use in pt <12months.
• No capsulorrhaphy + higher AVN

• Younger pt with open triradiate
• Cut: ileum > sciatic notch

• Older children: poor symphysis rotation + open triradiate
• Salter osteotomy: sup/inf pubic rami

Posterior column

Open triradiate + DDH


Reduces acetabular volume

DEGA

Cut above acetabulum to sciatic notch > displace acetabulum medially

• Cotyloid fossa and quadrilateal surface
• Age 18 months

6 months

Postero superior

Antero superior in DDH

• Flexion/extension
• Extension

• AIN
• Radial
• Ulnar: flexion type

• CRITOE
• capitellum: 1
• RadiAL HEAD: 4
• Medial epicondyle: 6
• Trochlea: 8
• Olecranon: 10
• Lateral epicondyle: 12

• Type I: Undisplaced > conservative
• Type II: Displaced + posterior cortex intact > CRPP
• Type III: Displaced posterior hinge not intact > CRPP
• Type IV: Unstable in flex/ext

• -Flex DIP thumb or D2
• - Wrist/finger extension

Should intersect the middle 1/3 of capitellum

• - Line parallel to humeral shaft + lateral condyle physis on AP
• - 70-75: compare to contralateral side

Medial column comminution

CLosed +/- open reduction internal fixation: NO gaps in reduction (  artery kink)

• No diffference clinically
• crossed have more torsional strenght

Palpate and put pin with elbow in extension

Cubitus varus deformity

Flexion type

3-4 weeks

Pin both: compartment